Fluid management in Critical Care



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Goals

Euvolaemia

Sodium 135-145 mmol/l

Assess uid balance

Fluid overload: postive uid balance, oedema, AKI, CVP >62

Volume loss (isotonic dehydration):
• Bleeding
• GI (vomiting, diarrhoea): →Na, ↑Hb1, ↑urea

Water de cit (hypotonic dehydration): ↑Na, ↑Hb1, ↑urea

1Hb may not be raised for other reasons
2If no other cause for CVP to be high e.g. heart failure

Treat

Fluid overload - RRT, diuretics/natriuretics - see below

Bleeding - stop the bleeding, aim for MAP 60 or systolic 70-90 until bleeding
controlled with 250ml boluses compound sodium lactate. Once bleeding
controlled - packed red cells, correct clotting.
GI loss - compound sodium lactate to replace de cit
Water de cit - oral water / NG water / 5% glucose to replace de cit
Mixed picture - replace water and electrolyte de cit appropriately
Systemic in ammatory response syndromes (sepsis, pancreatitis, trauma, major surgery) do not
cause hypovolaemia and should not be treated with IV uid resuscitation

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Daily requirements

25-30 ml/kg/d water 1mmol/kg/d Na, K, Cl 50-100g/d glucose

Fluid intake in order of preference:

Oral - no additional IV uid if meeting requirements
NG - feed plus water - combined target 1.2mls/kg/h
IV:
• ↑Na - 5% glucose (+ 20 - 40 mmol K per L)
• →Na - 4% glucose 0.18% sodium chloride (+ 20 - 40 mmol K per L)
• ↓Na - No IV uid - see hyponatraemia guideline on
<50kg - 1500mls/24h*
50-80kg - 2000mls/24h*
>80kg - 2500mls/24h*
* subtract intake from other sources from administered volume (eg drug infusions)

Fluid removal

Renal Replacement Therapy (RRT) or diuretics/natriuretics

Goal is sodium (and water) removal
Targets:
• Euvolaemia
• Resolution of peripheral oedema, pulmonary oedema, AKI
• Neutral cumulative uid balance, normal weight
• Na 135-145
• CVP <6 (as long as not chronic ↑)

RRT Diuretics/natriuretics
• Preferred option if signi cant uid • Frusemide 10-50mg/h IV
overload plus
• Rate of uid removal with RRT up • Spironolactone 100mg BD NG
to max 12mls/kg/h plus/minus
• Monitor CVS stability • Aminophylline 10mg/h IV

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Full guideline

Additional notes

Clinical signs are non-speci c:

• ↓BP, ↑HR, ↓UO, ↑lactate, ↓peripheral perfusion, dry mouth are not speci c for volume status
• They are more likely to be due to other causes (e.g. vasodilatation or heart failure)

Kidney:
• AKI has several causes. In hospital, AKI is much more commonly caused by intrinsic factors
and uid overload (from elevated venous pressures) than hypovolaemia.
• Oliguria is part of the normal stress response and is non-speci c to volume status - it may be
due to either hypo or hypervolaemia or neither.

Sodium:
• Is dif cult for humans to excrete which gets worse with increasing illness severity.
• Causes water retention and uid overload.
• Hypernatraemia is usually a combination of xs Na administration and water de ciency. It is:
• associated with worse outcomes in ICU
• both completely avoidable and unacceptable

CVP
• Venous return = Mean Circulatory Filling Pressure - CVP
• Organ perfusion = arterial pressure - (compartment + venous pressures)
• CVP therefore opposes VR and organ blood ow and so should be as low as possible

Lactate
• Is generated from glycolysis which is stimulated by sympathetic activation (stress response,
B-agonists). It is metabolised by the liver.
• A high lactate is rarely due to hypovolaemia.

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